Letters
References I. Signer SF: Capgras' syndrome: the delusion of substitulion. J Clil/ Psychiarry 4K: 147-150. 19K7 2. Silva JA. Leong GB. Shaner AL: A classification system for misidenlification syndromes. Psychopalhology 23:27-:U.1990
3. Benton AL. des Hamsher K. Varney NR. et al: COII/rihllliol/s 10 Nellml'sycllOlogiclIl Asse.unlt'lI/: A Clil/iclIl MIII/· New York. Oxford University Press. 19K3 4. Warrington E: Rt'cogl/iliol/ Memory Tt'sl MIII/III1I. Berkshire. England. Nfer-Nelson Publishing Company. 19K4 11111.
5. Bidault E. Luaut': JP. Tzavaras A: Prosopagnosia and the delusional misidentification syndromes. in TIlt' DellIsiol/lIl Misitlt'lI/ijimliol/ Srl/tlmme.'·. edited by Christodoulou GN. Basel. Swit/.erland. Karger. 19K6. pp KO-91
Sertraline-Augmented Lithium Therapy ojOrganic Mood Syndrome SIR: Prior research has suggested that certain types of traumatic brain injury. particularly frontotemporal injury. may result in decreased serotonergic activity. 1 This case study presents evidence for the efficacy of combining two serotonergic agents. lithium and sertraline. in the treatment of organic mood syndrome secondary to frontotemporal brain injury.
Case Report The patient was a 56-year-old white female factory worker with no psychiatric history prior to a traumatic brain injury. While working on her roof. the patient fell approximalely 20 feel. hitting her head on a concrete driveway. The palient sustained severe injury 10 bilaleral frontal lobes and the left temporal lobe. requiring bilaleral frontal lobectomies. The patient had a very long recovery in the intensive care unit. followed by a significant rehabilitation period geared loward the retraining of activities of daily living. Approximalely 6 months after her initial injury. Ihe patient was discharged from rehabililation and moved in with her daughter-in-law and small grandson (her son was away in the military). For several weeks. the patient appeared to be adjusting relatively well but then began to exhibit episodes of severe irrilability. panicularly toward her grandson. Approximately 3 weeks prior to admission. the patient began to exhibit episodes of crying 472
without any clear provocation, and her mood cycled between irritability (with rage episodes) and extreme sadness with uncontrollable crying. The authors were consulted because Ihe family began to fear for the young grandson's life in the face of the patient's irritabilily and rage toward him as well as other family members. The patienl's organic workup showed no abnormalities on blood chemistry profiles. and a head CT showed no change from her discharge 8 months before. Extensive interviewing, observation. and neuropsychological testing resulted in a diagnosis of organic mood syndrome. The patient was conceptually disorganized with flight of ideas and disconnecled thoughts. On the HAM-D (17 item). she received a score of IX. consistent with moderately severe depression. Her Brief Psychiatric Rating Scale (BPRS) prolile showed a score of 6 on the conceptual disorganization ilem. an anxious depression factor score of II. and an activalion/excitalion faclor score of 9. To stabilize her mood. the patient was stancd on a regimen of carbamazepine 100 mg bid. but this was discontinued after 3 days due \0 severe dizziness and increased confusion. On hospital Day 7. the patient was slaned on lilhium carbonate at 300 mg bid. which yielded a steady-state serum level ofO.X6 meqIL. Within 3 days of staning lithium. Ihe patient began 10 exhibil improvement in mood regulation and conceptual organizalion with no funher spontaneous l'rying or episodes of agitation or irritability. Her BPRS conceptual disorganization score decreased to I (mild). and her activation factor score decreased to 2 (mild). However. her HAM-D full score remained elevated at 15. Senraline at 50 mg qam was added to lithium therapy on hospital Day 12. Within 5 days. the patient's HAM-D score had dropped to 4. and she exhibiled no mood lability. conceptual disorganization. or anxious activation. The side-effect review was negative. and the patient was able to be discharged home 10 live with her family. withoul funher disruplions as of the time of this writing. The literature clearly documents the incidence of depression following traumatic brain injury.2..1 Recently. Bessette and Peterson 4 presented case data suggesting the efficacy of the selective serotonin reuptake inhibitor (SSRI) tluoxetine in the treatment of an organic mood syndrome secondary to a relatively mild head injury. In this case. we present evidence that PSYCHOSOMATICS
Letters
another SSRI, sertraline, can be a useful adjunct to lithium carbonate in the treatment of an extremely serious organic mood syndrome secondary to severe bilateral temporofrontal brain damage. The relatively benign side-effect profile of this agent, particularly the absence of anticholinergic effects, makes it potentially very useful in such settings. Further controlled studies are needed to more carefully assess the suggestions made by this case study. Edward A. Workman. Ed.D.. M.D. Daniel P. Harrington. M.D. University of Virginia School of Medicine Roanoke/Salem Program Roanoke. VA References I. Van Woerkom T. Teelken A. Minderhoud J: Difference
in neurotransmitter melabolism in fronlotemporal lohe contusion and diffuse cerebral contusion. Lallal I:X 12XI3.1977 2. Saran AS: Depression after minor closed head injury: role of dexamethasone suppression tesl and antidepressants. J Clill P.'.I"chialrr 46:335-33X. 19X5 3. O'Shanick GJ: Neuropsychiatric se4uclae of minor head injury. Ad,. PsrcllOsolll Med 16: 173-19.~. 19X6 4. Bessette RF. Peterson LG: Fluoxeline and organic mood syndrome. PS\·cho.mlllalics 33:22+-226. 1992
Sexually Transmitted Spreading ofHIV Infection: "Bridging Population" or "Suckback Movement"? SIR: The spread of HIV infection is continuing to increase. In Western Europe there has been a sharp rise in transmission through homosexual and bisexual sexual relations. What is more. it can be foreseen that the sexual mode will be the main mode of infection in the near future. For this reason we decided to see whether there are psychological traits or social variables that characterize seropositive subjects who most frequently indulge in sexually risky behaviors. The preliminary study carried out on 157 patients
VOLUME
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• NUMBER 4· FALL 1992
indicates that certain characteristics are quite interesting with regard to prevention. From a clinical and psychometric assessment, it seems that indulging in sexual behaviors with the risk of contagion is not related to specific personality or sociodemographic characteristics, nor even to the stage of the disease (even while excluding those situations in which the absence of this behavior is sustained by contingent reasons, independent of the subject's will). Acting out seems to be activated by situations of emotional crisis (in the sense in which Caplan uses it) or by psychosocial problems, which may involve seropositive subjects. In the light of these first data, it does not seem to be justifiable to speak of a "bridging population" to indicate those subjects responsible for the sexual spreading of the contagion. The hypothesis seems to be gaining ground that acting out takes place through a "suckback" movement that is determined by situations of emotional crisis in which the subject is incapable of mental elaboration and sees no other way out than resorting to acting out. It is clear that this movement, which could involve the whole seropositive population, seems to be less predictable and looks like it is going to be much more difficult to control than the bridging movement. However. it also suggests the need for adequate social support and a psychological intervention that is specific and specially conceived. such as crisis intervention. I , Claudio De Bertolini Marcella Baldo University of Padua Padova. Italy
References I. Caplan G: All Approach 10 COllllllllllily Me/llal Heallh. New York. Grune & Stratton. 1961 2. Caplan G: Prillciples of Pn"'c'/IIin' P.n·chialr.... New York. Basic Books. 1964 3. Flcgenheimer WV: Tc'chlliC/lIes of Bricl PsycllOlh('/"apy. New York. Jason Aronson. 19X2
References I. Signer SF: Capgras' syndrome: the delusion of substitulion. J Clil/ Psychiarry 4K: 147-150. 19K7 2. Silva JA. Leong GB. Shaner AL: A classification system for misidenlification syndromes. Psychopalhology 23:27-:U.1990
3. Benton AL. des Hamsher K. Varney NR. et al: COII/rihllliol/s 10 Nellml'sycllOlogiclIl Asse.unlt'lI/: A Clil/iclIl MIII/· New York. Oxford University Press. 19K3 4. Warrington E: Rt'cogl/iliol/ Memory Tt'sl MIII/III1I. Berkshire. England. Nfer-Nelson Publishing Company. 19K4 11111.
5. Bidault E. Luaut': JP. Tzavaras A: Prosopagnosia and the delusional misidentification syndromes. in TIlt' DellIsiol/lIl Misitlt'lI/ijimliol/ Srl/tlmme.'·. edited by Christodoulou GN. Basel. Swit/.erland. Karger. 19K6. pp KO-91
Sertraline-Augmented Lithium Therapy ojOrganic Mood Syndrome SIR: Prior research has suggested that certain types of traumatic brain injury. particularly frontotemporal injury. may result in decreased serotonergic activity. 1 This case study presents evidence for the efficacy of combining two serotonergic agents. lithium and sertraline. in the treatment of organic mood syndrome secondary to frontotemporal brain injury.
Case Report The patient was a 56-year-old white female factory worker with no psychiatric history prior to a traumatic brain injury. While working on her roof. the patient fell approximalely 20 feel. hitting her head on a concrete driveway. The palient sustained severe injury 10 bilaleral frontal lobes and the left temporal lobe. requiring bilaleral frontal lobectomies. The patient had a very long recovery in the intensive care unit. followed by a significant rehabilitation period geared loward the retraining of activities of daily living. Approximalely 6 months after her initial injury. Ihe patient was discharged from rehabililation and moved in with her daughter-in-law and small grandson (her son was away in the military). For several weeks. the patient appeared to be adjusting relatively well but then began to exhibit episodes of severe irrilability. panicularly toward her grandson. Approximately 3 weeks prior to admission. the patient began to exhibit episodes of crying 472
without any clear provocation, and her mood cycled between irritability (with rage episodes) and extreme sadness with uncontrollable crying. The authors were consulted because Ihe family began to fear for the young grandson's life in the face of the patient's irritabilily and rage toward him as well as other family members. The patienl's organic workup showed no abnormalities on blood chemistry profiles. and a head CT showed no change from her discharge 8 months before. Extensive interviewing, observation. and neuropsychological testing resulted in a diagnosis of organic mood syndrome. The patient was conceptually disorganized with flight of ideas and disconnecled thoughts. On the HAM-D (17 item). she received a score of IX. consistent with moderately severe depression. Her Brief Psychiatric Rating Scale (BPRS) prolile showed a score of 6 on the conceptual disorganization ilem. an anxious depression factor score of II. and an activalion/excitalion faclor score of 9. To stabilize her mood. the patient was stancd on a regimen of carbamazepine 100 mg bid. but this was discontinued after 3 days due \0 severe dizziness and increased confusion. On hospital Day 7. the patient was slaned on lilhium carbonate at 300 mg bid. which yielded a steady-state serum level ofO.X6 meqIL. Within 3 days of staning lithium. Ihe patient began 10 exhibil improvement in mood regulation and conceptual organizalion with no funher spontaneous l'rying or episodes of agitation or irritability. Her BPRS conceptual disorganization score decreased to I (mild). and her activation factor score decreased to 2 (mild). However. her HAM-D full score remained elevated at 15. Senraline at 50 mg qam was added to lithium therapy on hospital Day 12. Within 5 days. the patient's HAM-D score had dropped to 4. and she exhibiled no mood lability. conceptual disorganization. or anxious activation. The side-effect review was negative. and the patient was able to be discharged home 10 live with her family. withoul funher disruplions as of the time of this writing. The literature clearly documents the incidence of depression following traumatic brain injury.2..1 Recently. Bessette and Peterson 4 presented case data suggesting the efficacy of the selective serotonin reuptake inhibitor (SSRI) tluoxetine in the treatment of an organic mood syndrome secondary to a relatively mild head injury. In this case. we present evidence that PSYCHOSOMATICS
Letters
another SSRI, sertraline, can be a useful adjunct to lithium carbonate in the treatment of an extremely serious organic mood syndrome secondary to severe bilateral temporofrontal brain damage. The relatively benign side-effect profile of this agent, particularly the absence of anticholinergic effects, makes it potentially very useful in such settings. Further controlled studies are needed to more carefully assess the suggestions made by this case study. Edward A. Workman. Ed.D.. M.D. Daniel P. Harrington. M.D. University of Virginia School of Medicine Roanoke/Salem Program Roanoke. VA References I. Van Woerkom T. Teelken A. Minderhoud J: Difference
in neurotransmitter melabolism in fronlotemporal lohe contusion and diffuse cerebral contusion. Lallal I:X 12XI3.1977 2. Saran AS: Depression after minor closed head injury: role of dexamethasone suppression tesl and antidepressants. J Clill P.'.I"chialrr 46:335-33X. 19X5 3. O'Shanick GJ: Neuropsychiatric se4uclae of minor head injury. Ad,. PsrcllOsolll Med 16: 173-19.~. 19X6 4. Bessette RF. Peterson LG: Fluoxeline and organic mood syndrome. PS\·cho.mlllalics 33:22+-226. 1992
Sexually Transmitted Spreading ofHIV Infection: "Bridging Population" or "Suckback Movement"? SIR: The spread of HIV infection is continuing to increase. In Western Europe there has been a sharp rise in transmission through homosexual and bisexual sexual relations. What is more. it can be foreseen that the sexual mode will be the main mode of infection in the near future. For this reason we decided to see whether there are psychological traits or social variables that characterize seropositive subjects who most frequently indulge in sexually risky behaviors. The preliminary study carried out on 157 patients
VOLUME
.~.~
• NUMBER 4· FALL 1992
indicates that certain characteristics are quite interesting with regard to prevention. From a clinical and psychometric assessment, it seems that indulging in sexual behaviors with the risk of contagion is not related to specific personality or sociodemographic characteristics, nor even to the stage of the disease (even while excluding those situations in which the absence of this behavior is sustained by contingent reasons, independent of the subject's will). Acting out seems to be activated by situations of emotional crisis (in the sense in which Caplan uses it) or by psychosocial problems, which may involve seropositive subjects. In the light of these first data, it does not seem to be justifiable to speak of a "bridging population" to indicate those subjects responsible for the sexual spreading of the contagion. The hypothesis seems to be gaining ground that acting out takes place through a "suckback" movement that is determined by situations of emotional crisis in which the subject is incapable of mental elaboration and sees no other way out than resorting to acting out. It is clear that this movement, which could involve the whole seropositive population, seems to be less predictable and looks like it is going to be much more difficult to control than the bridging movement. However. it also suggests the need for adequate social support and a psychological intervention that is specific and specially conceived. such as crisis intervention. I , Claudio De Bertolini Marcella Baldo University of Padua Padova. Italy
References I. Caplan G: All Approach 10 COllllllllllily Me/llal Heallh. New York. Grune & Stratton. 1961 2. Caplan G: Prillciples of Pn"'c'/IIin' P.n·chialr.... New York. Basic Books. 1964 3. Flcgenheimer WV: Tc'chlliC/lIes of Bricl PsycllOlh('/"apy. New York. Jason Aronson. 19X2
